Services for people with rheumatoid arthritis - INTERNATIONAL COMPARISONS
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Services for people with rheumatoid arthritis INTERNATIONAL COMPARISONS
International comparisons
1 In this paper, the National Audit Office has reviewed Approaches to diagnosis
published literature about rheumatoid arthritis and
approaches to the disease to provide an international 4 Whilst there is consensus that diagnosis should
overview. The paper covers: be made as early as possible so that treatment can
commence, there is no single European or international
Prevalence and incidence method of diagnosing rheumatoid arthritis and no single
Approaches to diagnosis diagnostic test to detect it. Diagnostic tests are often
selected by the patient’s GP or rheumatologist, depending
Approaches to treatment and management on their assessment of the individual and the nature of
Approaches to timescales for treatment their rheumatoid arthritis.
Costs and financial arrangements 5 The UK, USA and Canadian GP curricula (Royal
College of General Practitioners9, American Academy of
Attitudes towards rheumatoid arthritis
Family Physicians10, The College of Family Physicians of
Rheumatoid arthritis and work Canada11) stipulate that GPs should be able to recognise,
diagnose and support the treatment of rheumatoid arthritis.
Overview of comparisons
The Royal Australian College of General Practitioners are
drawing up a new curriculum but currently provide a
Prevalence and incidence rheumatoid arthritis specific guideline12.
2 Prevalence of rheumatoid arthritis has been estimated 6 A selection of observational criteria (versions of
to be 0.5–1.5 per cent worldwide1. It is normally two to the American College of Rheumatology criteria are
three times more common in women than men2 and peak most common in the countries within the Organisation
age of onset internationally is generally between the ages for Economic Co-operation and Development13) and
of 35 and 453. At present there is no evidence that explains then various scanning techniques are used (Magnetic
unanimously the reasons for variations in prevalence of the Resonance Imaging is increasingly preferred to x-ray14)
disease (see Table 1 on page 6). alongside blood tests such as the Erythocyte Sedimentation
Rate and C-Reactive Protein tests. The use of rheumatoid
3 There are no accurate projections of the future factor testing of blood is common, but clinicians advocate
prevalence of rheumatoid arthritis, and although some caution as around 25 per cent of people with rheumatoid
studies have suggested a fall in rheumatoid arthritis arthritis will never have a positive rheumatoid factor15, 16.
incidence in some countries, these are not conclusive. A
Finnish study reported a ten per cent decline in rheumatoid
arthritis between 1980 and 19904; research reported
1.3 million adults in the USA with rheumatoid arthritis in
2005 down from the 1990 estimate of 2.1 million5 and
a UK study noted a fall in incidence, especially among
women6. Japanese7 and Finnish8 researchers have also
pointed towards an increasing age of onset.
SERVICES FOR PEOPLE WITH RHEUMATOID ARTHRITIS – INTERNATIONAL COMPARISONS 3Approaches to treatment and although they are usually run by arthritis charities rather
than the healthcare system. In the USA, for instance, the
management American National Centre for Chronic Disease Prevention
7 There is international consensus that a multi- and Health Promotion funds arthritis programmes in
disciplinary approach is the best way to manage twelve states26. American27 and Dutch28 researchers
rheumatoid arthritis, although the way in which the have demonstrated the benefit of exercise for rheumatoid
treatment is delivered varies widely. Few Health arthritis patients, but no long-term studies have been done.
Departments, with some exceptions, for example,
England and Wales17, and Australia18, have published Approaches to timescales for treatment
management guidelines for rheumatoid arthritis (Table 1).
12 There is consensus that the earliest diagnosis
8 Treatment should begin as soon as possible after and shortest time to treatment after onset of symptoms
symptom onset, and whilst there are many effective drugs enable treatment of rheumatoid arthritis to be most
used as part of rheumatoid arthritis treatment, the use of effective, and evidence that all therapies – monotherapy,
particular drugs and the time it takes to access new drugs combination DMARDs, biologics – work better in early
varies widely. In countries with state-funded healthcare, disease than in long-established rheumatoid arthritis29.
government guidelines set out the pathway to biologics, Published guidelines set out expected timescales for
often with a requirement to use conventional DMARDs referral for diagnosis and treatment (Table 1). Countries
(Disease-Modifying Anti-Rheumatic Drugs) first and with government-generated guidelines tend to be better at
limits on sequential use. Similar restrictions on the use achieving target times, more so than those countries with
of biologics exist in countries without a national health advisory guidelines from independent bodies.
service, as a result of health insurance policy restrictions.
13 Guidelines all advocate the prescription of DMARDs
9 Surgery is universally used to treat irreversible joint within three months of diagnosis and each of the countries
damage, and to restore joint function and limit pain19. reviewed has clinical management guidelines for the
It is, however, becoming less common as a method of use of each drug. France, Sweden and The Netherlands
treating rheumatoid arthritis20. Revision is more frequent suggest a shorter time to the start of DMARD treatment
in hip replacement as joints loosen and dislocate early21 than the UK30. Treatment strategies are moving towards
and there are problems with infection and continuing earlier, more aggressive use of DMARDs, for example
synovitis in knee replacement22. in the USA, The Netherlands and Sweden, and earlier
treatment with biologics.
10 There is no consensus as to the location or personnel
that should be responsible for the follow-up treatment for 14 We found a lack of evidence about the length of
people with rheumatoid arthritis; the importance instead time taken from symptom onset to treatment of people
rests on the skills which the medical staff possess and their with rheumatoid arthritis. Few studies have established
ability to treat rheumatoid arthritis effectively. Follow-up the length of time taken by people to present to either a
after diagnosis in countries such as France and Germany is GP or a rheumatologist, although there are sub-national
largely done by the GP, and Canadian healthcare is moving studies such as the Early Rheumatoid Arthritis Network
toward this; whereas The Netherlands and Scandinavia and the Norfolk Arthritis Register in the UK which provide
favour consultant rheumatologists. Specialist nurses, valuable data about the patient journey. Waiting times for
however, most often work in a hospital-based setting, rheumatoid arthritis referrals are not separately identified
in close liaison with a rheumatologist. Sweden has an and are usually measured as part of referral to treatment
extensive network of rheumatoid arthritis specialist nurses, times for general rheumatology services. For example, in
nurse-led clinics and even an arthritis-specific hospital23. England, under the 18 week referral to treatment standard,
the Department of Health collects data that shows the
11 Self-management and exercise programs are now length of time people wait for the rheumatology specialty.
more commonly used in rheumatoid arthritis treatment24 As in other countries, collection of condition specific data
and the long-term maintenance of self-efficacy and would increase the data burden upon the NHS.
psychological well-being have been reported through
such programmes25. As a result, such programs are
now promoted by each of the countries reviewed here,
4 SERVICES FOR PEOPLE WITH RHEUMATOID ARTHRITIS – INTERNATIONAL COMPARISONSCosts and financial arrangements Rheumatoid arthritis and work
15 Musculoskeletal diseases are universally within 18 Evidence suggests that within ten years of onset,
the top three costs to the healthcare system, when listed 50 per cent of people with rheumatoid arthritis will no
by disease. For people with rheumatoid arthritis, overall longer be at work38 and such figures are similar among
costs are significant because of the need for continuing the countries reviewed39. There is a lack of data covering
monitoring of the disease throughout life, depending the impact of rheumatoid arthritis on work and schemes
on the level of disease activity, and because of early to maintain the contribution of people with rheumatoid
withdrawal from the workforce owing to disability. The arthritis in the workplace; but studies from England40 and
complex nature of care for rheumatoid arthritis makes the Netherlands41 have highlighted the importance of
it difficult to identify total costs for the healthcare of occupational therapy, self-management techniques such
an individual with the disease; studies have however as pacing, and the attitudes of employers and colleagues.
compiled expenditure figures by country for drugs and
some medical costs31,32,33,34. Other studies have reviewed
the literature covering the health and cost burden of Overview of comparisons
rheumatoid arthritis (Table 2 on page 8).
19 In the literature, prevalence of rheumatoid arthritis
in north America (Canada, USA) and northern and middle
16 Personal healthcare insurance policies have only
European countries is higher than in southern European
recently started to fund biologics for rheumatoid arthritis
countries. Prevalence and incidence data are, however,
patients. Basic compulsory insurance on the continent
estimated as no country compiles national registers
does now cover biologics, but social insurance in
specifically recording numbers of people diagnosed with
countries such as Germany requires that at least two
rheumatoid arthritis, although the UK is relatively well
DMARDs are trialled prior to biologics treatment. Within
served for data about the rheumatoid arthritis population
each country, no state healthcare system funds alternative
with the national GP Research Database and ongoing
therapies, although health bodies are starting to use
studies such as the Norfolk Arthritis Register (NOAR).
hydrotherapy as part of rheumatoid arthritis treatment.
The NHS in England has around one rheumatologist per
100,000 population, which is a lower ratio than countries
Attitudes towards rheumatoid arthritis such as France, Sweden and the USA, but higher than,
for example, Spain and Ireland. Data from 2007 indicate
17 Despite the World Health Organisation Bone that fewer people with rheumatoid arthritis in the UK
and Joint Decade 2000-2010 and fundraising schemes receive biologics than in other comparable countries42,43.
including ‘Arthritis Week’ and ‘Arthritis Walk’ proving There are, however, more detailed rheumatoid arthritis
popular in countries such as Australia35 and the USA36 guidelines and pathways in the UK than elsewhere.
there is comparatively little public awareness of
arthritis charities in the UK. Although there are active 20 For the NHS in England, the 18 week referral to
support groups in each country we have reviewed, treatment standard is in the upper range of suggested times
there is a paucity of studies comparing international from referral to treatment, however this is a government
attitudes towards, and public awareness of, rheumatoid set minimum standard rather than a purely advisory target
arthritis. Often voluntary support groups and charities time for intervention, as in some other countries. With
provide the most easily accessible information about regard to anti-TNF affordability the UK ranks behind
rheumatoid arthritis and national health department several other OECD countries, mostly as a result of lower
websites frequently provide links to arthritis charities. relative health expenditure per capita44. Whilst many
There is, however, still a lack of public knowledge about rheumatoid arthritis charities work more closely with the
rheumatoid arthritis,37 mainly because its prevalence NHS than in many of the other countries we reviewed,
is dwarfed by that of osteoarthritis, which it is often the general lack of public awareness about the disease is
confused with. a concern across OECD countries, with calls for increased
public awareness and recognition of symptoms at an early
stage45.
SERVICES FOR PEOPLE WITH RHEUMATOID ARTHRITIS – INTERNATIONAL COMPARISONS 51 International comparisons of rheumatoid arthritis
Estimated number of people with Estimated adult prevalence 15+ Number of rheumatologists
rheumatoid arthritis (%)9 per ‘000 population10
England 580,0001 1.40 1/10011
Scotland 35,0002 0.83 1/11311
Wales 21,0003 0.87 1/10611
Northern Ireland 10,0004 0.75 1/11511
Sweden 60,0005 0.80 1/4512
Germany 544,0005 0.77 1/14213
France 283,0005 0.57 1/2514
The Netherlands 108,0005 0.81 1/8015
Ireland 40,0006 1.22 1/22716
Spain 197,0005 0.53 1/14017
Australia 400,0007 2.45 1/8818
USA 1,976,0005 0.83 1/5014
Canada 320,0008 1.20 1/7419
NOTES
Estimated number of people with rheumatoid arthritis
1 England – National Audit Office (2009). Services for people with rheumatoid arthritis.
2 Scotland – NRAS, 2006. The State of Inflammatory Arthritis Service in Scotland. www.rheumatoid.org.uk/download.php?asset_id=206&link=true
3 Wales – based on Symmons, D. et al., 2002. The prevalence of rheumatoid arthritis in the United Kingdom: new estimates for a new century.
Rheumatology, 41(7), pp.793-800.
4 Northern Ireland – Northern Ireland Office. New Ultrasound Scheme – a first for Northern Ireland. www.nio.gov.uk/media-detail.htm?newsID=3799
5 Sweden/ Germany/The Netherlands/France/Spain/USA - Lundkvist, J. Kastäng, F. & Kobelt, G., 2007. The burden of rheumatoid arthritis and access
to treatment: health burden and costs. The European Journal of Health Economics, 8(2), pp.49-60.
6 Ireland – Arthritis Ireland. www.arthritisireland.ie/info/facts.php
7 Australia – Australian Institute of Health and Welfare, 2009. A picture of rheumatoid arthritis in Australia. www.aihw.gov.au/publications/phe/phe-
110-10524/phe-110-10524.pdf
8 Canada – The Arthritis Society. www.arthritis.ca/resources%20for%20advocates/capa/resources/brief/ucb/default.asp?s=1
Estimated adult prevalence
9 Prevalence figures have been calculated from the number of people with rheumatoid arthritis as a percentage of the adult population, according to
2005 population statistics from the United Nations. For England, Scotland, Wales, Northern Ireland, calculated for adults 16+ using mid 2007
population data from the Office for National Statistics.
Number of rheumatologists
10 These data are indicative since the registration required of rheumatologists varies between countries and the extent to which they use specialist nurses,
for example, may differ. These data do not take account of these differences.
11 UK – Harrison, M.J. Deighton, C. & Symmons, D.P.M., 2008. An update on UK rheumatology consultant workforce provision: the BSR/ARC Workforce
Register 2005-07: assessing the impact of recent changes in NHS provision. Rheumatology, 47(7), pp.1065-1069
12 Sweden – Extrapolated from: Arvidsson, B., Jacobsson, L. & Petersson, I.F., 2003. Rheumatology Care in Sweden – the role of the nurse.
Musculoskeletal Care, 1(2), pp.81-83.
13 Germany – Deutsche Rheuma Liga, 2007. Fakten über Rheuma. www.rheuma-liga.de/uploads/0/publikationen/merkblaetter/merkblatt_6.7_aktuell.pdf
14 France/USA - Jönsson, B., Kobelt, G. & Smolen, J., 2008. The burden of rheumatoid arthritis and access to treatment: uptake of new therapies.
The European Journal of Health Economics, 8(2), pp.61-86.
15 The Netherlands - Harrison, M.J. Deighton, C. & Symmons, D.P.M., 2008. An update on UK rheumatology consultant workforce provision: the BSR/
ARC Workforce Register 2005-07: assessing the impact of recent changes in NHS provision. Rheumatology, 47(7), pp.1065-1069
16 Ireland – Irish Society of Rheumatology Manpower Committee, 2002. Rheumatology Manpower. www.isr.ie/_fileupload/File/ISR%20
Rheumatology%20 Manpower%20document%202002.doc
6 SERVICES FOR PEOPLE WITH RHEUMATOID ARTHRITIS – INTERNATIONAL COMPARISONSDiagnostic criteria Are government Suggested maximum Is access to a
guidelines applied to referral to treatment specialist normally
rheumatoid arthritis? guidelines/standard only on referral from
(weeks) a GP?33
Modified ARA/ACR Yes20 18 Yes
Key
21
Revised 1987 ARA/ACR Yes 12 Yes ARA/ACR – Classification
criteria for rheumatoid
1987 ARA/ACR Yes22 18 Yes
arthritis were first
1987 ARA/ACR Yes23 6 Yes proposed by the
American Rheumatoid
24
Modified ARA/ACR Yes 6 Yes Association (ARA) in
1987 ARA/ACR No25 6 No 1958. The 1958 criteria
were revised in 1987 by
1987 ARA/ACR No26 6 No the American College of
Rheumatology (ACR). See
1987 ARA/ACR No27 6 Yes
Symmons. D, Mathers.
1987 ARA/ACR No 28 – – C, Pfleger. B. (2003)
The global burden of
1987 ARA/ACR No29 15 days No rheumatoid arthritis in the
year 2000.
1987 ARA/ACR Yes30 Urgency dependent Yes
Modified ARA/ACR No31 –
32
Modified ARA/ACR Yes – Yes
17 Spain – Symmons, D.P. Jones, S. Silman, A.J., 2003. Manpower. British Journal of Rheumatology, 32 (Supplement 4), pp.18-21.
18 Australia – Australian Institute of Health and Welfare, 2006. www.aihw.gov.au/publications/hwl/mlf06/mlf06-xx-specialists-and-specialists-in-
training.xls
19 Canada - Harrison, M.J. Deighton, C. & Symmons, D.P.M., 2008. An update on UK rheumatology consultant workforce provision: the BSR/ARC
Workforce Register 2005-07: assessing the impact of recent changes in NHS provision. Rheumatology, 47(7), pp.1065-1069
Guidelines applied to rheumatoid arthritis
EULAR – recommendations for the management of early arthritis, EULAR * – European Action towards Better Musculoskeletal Health
20 Musculoskeletal Services Framework; NICE clinical guidelines and technology appraisals
21 SIGN: Management of early arthritis; some NICE technology appraisals
22 Service Development and Commissioning Directives: Arthritis and Chronic Musculoskeletal Conditions; NICE clinical guidelines and technology appraisals
23 Strategic Review of Rheumatology Services in Northern Ireland 2005; NICE clinical guidelines and technology appraisals
24 1998 National Guidelines; EULAR; EULAR *
25 EULAR; EULAR *
26 Société Français de Rhumatologie: Recommandations sur l’utilisation des anti-TNF-a; AFLAR: Support Medical : De la polyarthrite rhumatoide à la
crise de goutte; EULAR; EULAR *
27 EULAR; EULAR *
28 ACR Guidelines for the Management of Rheumatoid Arthritis
29 GUIPCAR Group: Clinical practice guideline for the management of RA in Spain; EULAR; EULAR *
30 Better Arthritis and Osteoporosis Care Initiative 2006-2009; National Improvement Framework for Osteoarthritis, Rheumatoid Arthritis
and Osteoporosis
31 ACR Guidelines for the Management of Rheumatoid Arthritis
32 Guidelines & Protocols Advisory Committee Rheumatoid Arthritis: Diagnosis and Management; ACR Guidelines for the Management of
Rheumatoid Arthritis
Specialist access from a GP
33 All except Australia, USA, Canada: Eurostat, 2002. Key data on health 2002 – Data 1970-2001.
SERVICES FOR PEOPLE WITH RHEUMATOID ARTHRITIS – INTERNATIONAL COMPARISONS 72 The medical cost burden of rheumatoid arthritis1,2,3
Medical costs excluding drugs Drug costs Per cent of patients on
(million €) (million €) anti-TNF drugs
United Kingdom 1,953 140 6
Sweden 125 137 12
Germany 1,649 1,051 4
France 2,101 1,259 8
Netherlands 265 64 11
Ireland 110 77 –
Spain 493 159 8
Australia 409 288 1
USA 8,755 14,275 21
Canada 701 562 7
NOTES
1 Medical costs and drug costs
Lundkvist, J. Kastäng, F. & Kobelt, G., 2007. The burden of rheumatoid arthritis and access to treatment: health burden and costs. The European Journal
of Health Economics, 8(2), pp.49-60.
2 Per cent on anti-TNF
Jönsson, B., Kobelt, G. & Smolen, J., 2008. The burden of rheumatoid arthritis and access to treatment: uptake of new therapies. The European Journal
of Health Economics, 8(2), pp.61-86.
3 The data are for indicative comparison as the studies on which the estimates are based were conducted at different points in time and cover different
time periods/years. Drug costs are likely to have increased over time, in particular after the introduction of biologics. Data for the UK have not been
amended to take account of NAO estimates for England.
Endnotes
1 Jonsson, B, 2008. Patient access to rheumatoid arthritis treatments. The European Journal of Health Economics
(2008) 8 (Suppl 2):S35–S38.
2 NRAS, 2006. What is RA? www.rheumatoid.org.uk/article.php?article_id=224
3 Bone and Joint Decade, 2005. European Action Towards Better Musculoskeletal Health.
Sweden: BJD Publication. www.boneandjointdecade.org/ViewDocument.aspx?ContId=534
4 Silman, A.J., 2002. The Changing Face of Rheumatoid Arthritis: Why the Decline in Incidence?
Arthritis & Rheumatism, 46(3), pp.579-581.
5 CDC, 2008. Arthritis Types – Overview. www.cdc.gov/arthritis/arthritis/rheumatoid.htm
6 Symmons, D. et al., 2002. The prevalence of rheumatoid arthritis in the UK: new estimates for a new century.
Rheumatology, 41(7), pp.793-800.
7 Imanaka, T. et al., 1997. Increase in age of onset of rheumatoid arthritis in Japan over a 30 year period.
Annals of the Rheumatic Diseases, 56(5), pp.313-316.
8 Kaipiainen-Seppanen, O. et al., 1996. Shift in the incidence of rheumatoid arthritis towards elderly patients in
Finland during 1975-1990. Clinical and Experimental Rheumatology, 14, pp.537-542.
9 RCGP, 2007. Rheumatology and Conditions of the Musculoskeletal System (including Trauma).
www.rcgp-curriculum.org.uk/pdf/curr_15.9_Rheumatology_and_Musculoskeletal_System2.pdf
8 SERVICES FOR PEOPLE WITH RHEUMATOID ARTHRITIS – INTERNATIONAL COMPARISONS10 AAFP, 2008. Recommended Curriculum Guidelines for Family Medicine Residents - Rheumatic Conditions.
www.aafp.org/online/etc/medialib/aafp_org/documents/about/rap/curriculum/rheumaticconditions.Par.0001.File.
tmp/Reprint276.pdf
11 CFPC, 2008. National Undergraduate Family Medicine Learning Goals and Objectives. www.cfpc.ca/local/files/
Education/sot/Undergraduate%20Goals%20and%20Objectives.pdf
12 RACGP, 2008. Rheumatoid Arthritis Clinical Guideline. www.racgp.org.au/Content/NavigationMenu/
ClinicalResources/RACGPGuidelines/Arthritis/RAguideline.pdf
13 European Commission, 2003. Indicators for Monitoring Musculoskeletal Problems and Conditions –
Musculoskeletal Problems and Functional Limitation. www.ec.europa.eu/health/ph_projects/2000/monitoring/
fp_monitoring_2000_frep_01_en.pdf
14 Ostergaard, M. & Szkudlarek, M., 2003. Imaging in rheumatoid arthritis - why MRI and ultrasonography can no
longer be ignored. Scandinavian Journal of Rheumatology, 32(2), pp.63-73.
15 NHS, Central Manchester and Manchester Children’s University Hospitals. www.cmmc.nhs.uk/directorates/
labmedicine/departments/immunology/tests/40.pdf
16 Symmons, D.P.M., 2007. Classification criteria for rheumatoid arthritis – time to abandon rheumatoid factor?
Rheumatology, 46(5), pp.725-726.
17 NICE, 2009. Rheumatoid arthritis: the management of rheumatoid arthritis in adults. www.nice.org.uk/
Guidance CG79
18 Department of Health and Ageing, 2007. National Service Improvement Framework for Osteoarthritis, Rheumatoid
Arthritis and Osteporosis. www.health.gov.au/internet/main/publishing.nsf/Content/pq-ncds-arthritis
19 ACR, 2002. Guidelines for the Management of Rheumatoid Arthritis 2002 Update. Arthritis & Rheumatism, 46(2),
pp.328-346.
20 NHS, 2007. Has hip surgery for Rheumatoid Arthritis moved on? www.library.nhs.uk/musculoskeletal/
viewResource.aspx?resID=260129&code=f3216ec38aac2f2c1efd972ef48cfd24
NHS, 2008. Has surgery for the rheumatoid hand and wrist moved on? www.library.nhs.uk/musculoskeletal/
ViewResource.aspx?resID=282782&tabID=290
21 NHS, 2007. Has hip surgery for Rheumatoid Arthritis moved on? www.library.nhs.uk/musculoskeletal/
ViewResource.aspx?resID=260129&tabID=290
22 NHS, 2007. Has surgery for the rheumatoid knee moved on in 2008? www.library.nhs.uk/musculoskeletal/
ViewResource.aspx?resID=282998&tabID=290
23 Arvidsson, B., Jacobsson, L. & Petersson, I.F., 2003. Rheumatology Care in Sweden – the role of the nurse.
Musculoskeletal Care, 1(2), pp.81-83.
24 Newman, S. Mulligan, K. & Steed, L., 2001. What is meant by self-management and how can its efficacy be
established? Rheumatology, 40(1), pp.1-4.
25 Barlow, J. et al., 2009. An 8-yr follow-up of Arthritis Self-Management Programme participants.
Rheumatology, 48(2), pp.128-133.
26 CDC, 2008. State Programs. www.cdc.gov/arthritis/state_programs/programs/index.htm
27 Anandarajah, A.P. & Schwarz, E.M., 2004. Dynamic exercises in patients with rheumatoid arthritis. Annals of the
Rheumatic Diseases, 63(11), pp.1359-1361.
SERVICES FOR PEOPLE WITH RHEUMATOID ARTHRITIS – INTERNATIONAL COMPARISONS 928 Van den Ende, CH. et al., 1998. Dynamic exercise therapy in rheumatoid arthritis: a systematic review. The British
Journal of Rheumatology, 37(6), pp.677-687.
29 Cush, J.J., 2007. Early Rheumatoid Arthritis – Is There a Window of Opportunity? Journal of Rheumatology,
Supplement, 80, pp.1-7.
30 Sokka, T et al., 2007. QUEST-RA: quantitative clinical assessment of patients with rheumatoid arthritis seen in
standard rheumatology care in 15 countries. Annals of the Rheumatic Diseases, 66(11), pp.1491-1496.
31 Jonsson B, 2008. Patient access to rheumatoid arthritis treatments. The European Journal of Health Economics
(2008) 8 (Suppl 2):S35–S38.
32 Lundkvist J et al, 2008. The burden of rheumatoid arthritis and access to treatment: health burden and costs.
The European Journal of Health Economics (2008) 8 (Suppl 2):S49–S61
33 Jonsson B et al, 2008. The burden of rheumtoid arthritis and access to treatment: uptake of new therapies.
The European Journal of Health Economics (2008) 8 (Suppl 2):S61–S86
34 Jonsson B et al, 2008. The burden of rheumatoid arthritis and access to treatment: determinants of access.
The European Journal of Health Economics (2008) 8 (Suppl 2):S86–S93.
35 Australian Institute of Health and Welfare. Arthritis Awareness Week. www.aihw.gov.au/arthritismsk/
arthritisweek_09.cfm
36 Arthritis Foundation. Arthritis Walk www.lmt.arthritis.org/arthritis-walk/index.php
37 Medical News Today, 2008. Better Interaction and Education Between Rheumatoid Arthritis Patients and Care
Providers Needed, New Study Indicates. www.medicalnewstoday.com/articles/127188.php
38 ARC, 2008. Fifty per cent of rheumatoid arthritis patients give up work within ten years, says new study. www.arc.
org.uk/news/DirectNews/Article.asp?ID=18456774&Year=2008&Month=2&NameOfMonth=February
39 Barrett, E.M. et al., 2000. The impact of rheumatoid arthritis on employment status in the early years of disease:
a UK community-based study. Rheumatology, 39(12), pp.1403-1409.
40 Barrett, E.M. et al., 2000. The impact of rheumatoid arthritis on employment status in the early years of disease:
a UK community-based study. Rheumatology, 39(12), pp.1403-1409.
41 Verstappen, S.M.M. et al., 2005. Working status among Dutch patients with rheumatoid arthritis: work disability
and working conditions. Rheumatology, 44(2), pp.202-206.
42 Sokka, T et al., 2007. QUEST-RA: quantitative clinical assessment of patients with rheumatoid arthritis seen in
standard rheumatology care in 15 countries. Annals of the Rheumatic Diseases, 66(11), pp.1491-1496
43 Jönsson, B. Kobelt, G. & Smolen, J., 2007. The burden of rheumatoid arthritis and access to treatment: uptake of
new therapies. The European Journal of Health Economics, 8(2), pp.61-86.
44 Jönsson, B. Kobelt, G. & Smolen, J., 2007. The burden of rheumatoid arthritis and access to treatment: uptake of
new therapies. The European Journal of Health Economics, 8(2), pp.61-86.
45 SIGN, 2001. New approach to treatment of rheumatoid arthritis could significantly reduce suffering for patients.
www.sign.ac.uk/about/press/pr1-2-01.html
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